Medico-legal Update, October-December 2020, Vol. 20, No. 4 739 Stye, Bacterial Eye Infection among the Students of the Technical Medical Institute, AL-Mansour

Mohammed Abed Jawad1, Taghreed Khudhur Mohammed2

1Ass. Lecturer, Clinical Laboratory Techniques, Al-Nosor University, Baghdad, Iraq, 2Professor, Institute of Medical Technology, Al-Mansour, The Middle Technical University, Baghdad, Iraq

Abstract Background: Eye stye is a local infection in the form of a red bump (a ) caused by a blockage and inflammation of the sebaceous glands whose secretions help to form tears. Approximately 90-95% of the causes of “stye” is an infection with , and it is possible that and lack of sleep contribute to the infection as well.

Method:The study was done at Institute of Medical Technology/al–Mansour/Baghdad from January 2018 till January of 2019. 100 eyes swab and Stye swab samples were collected from students suffered from eye redness and conjunctiva, which include 50 male and 50 female. The diagnoses of specimens were done by using the Analytical Profile Index System (API) for chemical tests and by culturing on enriched and selective culture media to isolate and diagnose the bacteria.

Results: The results showed that 57(57%) samples were positive for bacterial eye infections. The study showed high percentage of eye infection among students was due to Staphylococcus aureus bacteria, followed by Staphylococcus epidermides and Pseudomonas aeruginosa (61.40%, 35.08% and 3.50%respectively). Most of bacterial isolates were resistance to .

Conclusion: One of the most important conclusions is to go to the doctor or pharmacist to treat eye inflammation to avoid the occurrence of eye , burning and redness, and not to repeat the infection. Personal and general hygiene must also be taken care of to reduce the spread of bacteria that cause eye infections among people.

Keywords: Bacterial , Staphylococcus aureus, Stye, Hordeolum.

Introduction Swelling may form on the outer or on the inner eyelid. This condition usually lasts one to two weeks, Hordeolum or Stye is an acute bacterial infection and is usually self-healing. It can be treated with warm that occurs in the covering of the eye or eyelid. This compresses, massage therapy and some eye ointments[1]. infection is a common condition among Iraqi school and university students, and patients are often directed to go The doctor may treat a person with a stye by taking to a university doctor or health care center for diagnosis topical antibiotics, and in other cases, the removal of the and treatment. The patient suffers from painful eye stye may require surgical intervention. All age groups inflammation with redness and swelling of the eyelid. are affected by the infection, although there is a slight increase in the incidence rate among patients between the ages of 30 and 50 years, and with this, the infection may Corresponding Author: spread within the age groups between 5-20 years.Several Mohammed Abed Jawad researchers have found that there are no significant Ass. Lecturer, Clinical Laboratory Techniques, Al- differences in the prevalence between populations around Nosor University, Baghdad, Iraq the world. And most patients who suffer from chronic e-mail: [email protected] conditions such as dermatitis, diabetes, high blood fats 740 Medico-legal Update, October-December 2020, Vol. 20, No. 4 (such as cholesterol) and a large number of fast foods, Diagnosis of Staphylococcus aureus: pickles and sugars may be the cause of the spread of 1. The culture characteristics were studied in the infection[2]. Eye begging or humping eyes are the names culture media, and the shape and aggregation of the for furunculosis, or stye, in Latin. It is an inflammation bacteria were studied under light microscope using of the on the eyelid and the sweat the Gram stain [7]. glands known as the mole gland[3]. The lesion appears as a small, swollen, red lump containing [4]. The Stye of 2. Biochemical tests (oxidase, catalase and coagulase) the eye are similar to the sebaceous cyst, but it is smaller were performed. Mannitol fermentation using and more painful. Usually the infection is acute. Its the Mannitol salt agar medium was done [8]. duration is (7-10) days without treatment. The sebaceous [bioMérieux, France] API Staphylococcus kits were cyst is a chronic infection and it is one of the infections used to diagnose Staphylococcus aureus. [5]. that can only be treated with surgical intervention Diagnosis of Streptococcuspyogenes: One of the most important causes of Stye infection is the bacterial infection by Staphylococcus aureus for the 1. The culture characteristics were studied in the meibomian glands (the eyelid gland, which is one of culture media, and the shape and aggregation of the the sebaceous glands located in the eyelid,its secretions bacteria were studied under light microscope using [7]. prevent from sticking together)which increase the Gram stain. concurrently with poor nutrition, lack of sleep, poor 2. Biochemical tests were performed using the API personal and general hygiene, scrubbing the eyes with Streptococcus [bioMérieux, France] to diagnose contaminated hands and the use of contaminated devices species belonging to the genus Streptococcus. such as contaminated towels[4and5]. Staphylococcus aureus causes severe infections between 90% and 95% Diagnosis of Enterobacteriaceae (Gram-negative compared to other bacterial species such as Pseudomonas bacteria): aeruginosa, Haemophilus influenzae and Chlamydia 1. The culture characteristics were studied in the trachomatis[6].There are a number of research studies on culture media, and the shape and aggregation of the stye in Iraq and most of them were in primary schools, bacteria were studied under light microscope using but there is no study of a stye prevalence among students the Gram stain [7]. of the Medical Technical Institute/Al-Mansour.So, the 2. Biochemical tests were performed using the API20 aims of the current study are isolation and diagnosis of [bioMérieux, France] to diagnose species belonging Staphylococcus aureus, Staphylococcus epidermidis, and to the Enterobacteriaceae. Pseudomonas aeruginosa causing Eyelid inflammation eyelid inflammation from students of the Medical sensitivity test (disc diffusion Technical Institute\Al-Mansour\ Baghdad. method)[8]: Six antibiotics were used: (Cephalexin (LEX), Cefotaxime (CTX), (C), Materials and Method Gentamicin (GM), Tetracycline (TE), (E) (Hi Media Laboratories, India antibiotic discs). Samples collection and culturing on Enriched Antibiotic sensitivity was determined by measuring the and selective culture media: 100 swabs (50 females antibacterial inhibition diameter of bacterial isolates and 50 males) were collected from students of the on the Muller Hinton agar and comparing it with the Medical Technical Institute\ Al-Mansour, who suffer index numbers established in the Committee of National from Eyelid inflammation, swelling, localized eyelid Clinical Laboratory Standards (NCCLS)[9]. pain, redness, itching, , falling eyes and increased tear secretion. The samples collected during Results the period from January 2018 to January 2019. Their ages ranged between (19-25) years. All swabs were cultured 100 samples were collected from students of the in a streaking manner on the MacConkey agar, Blood Medical Technical Institute/Al-Mansour who were agar and Chocolate agar (Oxoid™ Company, UK) and apparently infected with eyelid inflammation and whose by two Petri dishes of each type of culture medium for ages ranged between (19-25) years and for both sexes each swab. The dishes were incubated at 37°C for 18-24 (50 females and 50 males) during the period between hours. The first group of plates was incubated in aerobic January 2018 until January 2019. The results showed that conditions, the second group in anaerobic conditions. 57 samples gave a positive result for bacterial growth on Medico-legal Update, October-December 2020, Vol. 20, No. 4 741 the enriched and selective culture media, with a range whose ages ranged between (19-26) years at Al-Anbar (57%, 57/100X100) of the total number of samples. University during 2009. The incidence of Staphylococci Bacterial isolates were isolated and diagnosed based bacteria was 83.32%, and Pseudomonas aeruginosa, on [8-11]. As its cultural and phenotypic properties were 67.16%.Also, they found that the sensitivity to antibiotics studied; the shape and aggregation of bacteria under was 5.69% for Erythromycin, 52% for Gentamycin, and the light microscope were identified after stained with 8.47% for Tetracycline. While recorded the highest Gram stain and examined under the X 100. After that, resistance to the antibiotic Penicillin, which was 93.6%, the bacteria were diagnosed using biochemical tests. The followed by Cephalexin with 93.6%, this may be due results showed the following: to the wrong and excessive use of these antibiotics by patients as well as their use of these antibiotics without Staphylococcus aureusgave white colonies with consulting a specialist doctor. beta-type hemolysis on Blood agar. Positive for coagulase and mannitol fermentation. Staphylococcus Table 1: Percentage of bacterial isolates from epidermides had white colonies without haemolysis patients with eyelid inflammation on Blood agar, positive for catalase, and negative for Number of coagulase and mannitol fermentation. The colonies Bacteria that cause eyelid inflammation isolates (%) of Pseudomonas aeruginosa appeared gray on blood agar, pale yellow and non-fermenting lactose sugar on Staphylococcus aureus 35 (61.40) MacConkey agar; positive for oxidase test and negative Staphylococcus epidermides 20 (35.08) for urease test and indole production. Pseudomonas aeruginosa 2 (3.50)

The highest percentage of eye infection among Total 57(100) students was due to Staphylococcus aureus bacteria The results of the current study showed that the (61.40%) (Table 1) and this is close to what Al-Abidi incidence of Staphylococcus aureus in females was more isolated in 2006, which was 52.4% for patients suffering than males, it was 55.55% and 64.10%, respectively. from eyelid inflammation in the province of Diwaniyah Whereas, the infection rate of Staphylococcus [12].Likewise, an approach to the Alash study in 2015, epidermidesand Pseudomonas aeruginosa was almost which was 31%, and the current study did not agree identical for males and females (Table 2). with the results of the same researcher’s findings for Staphylococcus epidermides and Pseudomonas Table 2: Percentage of bacterial isolates from aeruginosa, as the ratio was 10 (35%) and 7 (24%), patients with eyelid inflammation according to sex respectively [13]. The infection of Staphylococcus epidermides and Pseudomonas aeruginosa among Bacteria that cause eyelid Number of Number of Total Institute students was 35.08% and 3.50%. The results inflammation isolates in isolates in (%) of current study also did not match the results of the females males researcher Al-Abidi for Staphylococcus epidermides (%) (%) and Pseudomonas aeruginosa, which were 7.3% Staphylococcus aureus 25 (64.10) 10 (55.55) 35 (61.40) Staphylococcus epidermides 12 (30.76) 8 (44.44) 20 (35.08) and 14.6%, respectively. The researchers, Thewaini Pseudomonas aeruginosa 2 (5.1) 0 (0) 2 (3.50) and Abed-Al sahib, concluded in 2014 [14] that the Total 39 (100) 18 (100) 57 (100) percentage of bacterial infections with eye inflammation The results showed sensitivity to antibiotics after collecting 101 swabs from the eyes of patients who Cephalexin (LEX), Cefotaxime (CTX), Chloramphenicol visited Al-Hussein General Hospital and the Hindia (C), Gentamicin (GM), Tetracycline (TE), Erythromycin Hospital at Karbala in Iraq was 93%, distributed as (E) as follows: follows (conjunctivitis eye 2.78) %, Ocular eyelid infections 8.13% and tear sac infections, 9.7%). The • Staphylococcusaureus: 17.14% sensitive to CTX, results of culturing on enriched and differential culture LEX, E and C antibiotics; And it is sensitive to media showed that the percentage of Staphylococcus 51.42% to GM antibiotic and 5.71% to TE. aureus in both sexes is the most common cause. As for AL-ALani and others [15], their study included isolating • Staphylococcusepidermides: 17.14% sensitive to and diagnosing the bacteria that cause eye infection in CTX, LEX, E and C antibiotics; And it is sensitive university students who use contact lenses and eyeliner, to 51.42% to GM antibiotic and 5.71% to TE. 742 Medico-legal Update, October-December 2020, Vol. 20, No. 4 • Pseudomonasaeruginosa: The resistance rate was References 100% for all antibiotics under study. 1. Lindsley K, Nichols JJ and Dickersin K. The researchers Al-Dorri and Al-jebouri[16]were Non-surgical interventions for acute internal found that the causes of conjunctivitis and eyes redness in hordeolum. Cochrane Database Syst Rev. Tikrit General Hospital patients in 2004 were result from (2017);9(1):CD007742. Staphylococcus aureus, Streptococcus pneumoniae and 2. Carlisle RT, Digiovanni J. Differential Diagnosis Staphylococcus epidermides infection in percentages of the Swollen Red Eyelid. Am Fam Physician. 42%, 27% and 12%, respectively. Also, they were (2015);92(2):106-12. found that the isolates had the highest sensitivity to the 3. Deibel JP, Cowling K. Ocular inflammation and antibiotic norfloxacin. The current study did not agree infection. Emerg. Med. Clin. North Am. (2013); with the researchers ’study in relation to gender. The 31(2):387-97. researchers found that the percentage of infection with the bacteria that cause eye inflammation was higher 4. Lindsley K, Nichols JJ, Dickersin K. Interventions in men than it is in women, as it was 55% and 45%, for acute internal hordeolum. Cochrane Database respectively. In Babil Governorate, the researchers Syst Rev. (2010); 8(9):CD007742. Abid and Ewadh[17] found that bacterial etiology of 5. Pflipsen M, Massaquoi M, Wolf S. Evaluation eye inflammation, eyelid and tear cyst inflammation in of the Painful Eye. Am Fam Physician. (2016); patients reviewing a number of Hilla hospitals in 2012 93(12):991-8. was represented by a high incidence of Staphylococcus 6. McAlinden C, González-Andrades M, aureus followed by Escherichia coli with a percentage Skiadaresi E. Hordeolum: Acute abscess within of 38.06% and 2.7 % Respectively. As the patients suffer an eyelid sebaceous gland. Cleve Clin J Med. from the appearance of a point tending to yellow in the (2016);83(5):332-4. middle of the eye and then it turns into pus and spreads 7. Prescott, L.M.; Harley, J.P. and Klein, D. slightly to the surrounding area. A: Microbiology. 2nd ed., Wm. C. Brown The bacteria that cause eye inflammation can be Communication, Inc., England. (1993) easily transmitted from one person to another when 8. Bauer, A.M.; Kirbu, W.M.; Sherris, J.C. and using contaminated towels. So, hands should always be Turck, M.: Antibiotic susceptibility testing by washed with water, soap, sterilizers, and wash the face astandardized single disc method. Am. J. Clin. frequently; in addition to not use contact lenses until they Pathol., 45:493-496. (1966) are completely cured, and not wearing glasses between 9. National Committee for Clinical Laboratory people or wearing contact lenses or put contaminated eye (NCCLS): Performance Standard for Antimicrobic makeup, and it is also recommended to remove makeup Susceptibility Testing. NCCLS. Villanova, Pa. before bed. Azithromycin eye drops can be used after (1993). consulting a doctor or pharmacist as a topical treatment, 10. Betty, D.R.; Klein, J.O. and in order to avoid some complications such as bleeding Launay,V.:Epidemiology, Microbiology and from the eyelids or when the vision is not clear. In management of cojunctives paediatrician, Suppl. addition, students and their supervisors in colleges and 8:10-15.(1998) institutes should be advised to follow the aforementioned 11. Holt, J.G.; Krieg, N.R.; Sneath, P.; Staey, J.T. and advice in order to prevent the transmission of infections Williams, S.T: Bergeys. Manual of Determinative among the students. Sometimes it may be necessary to Bacteriology. 9th ed. Williams and Wilkius, USA. keep students in their homes to avoid transmitting the (1994) infection to colleagues[18]. 12. AL-Abidi, Hadaf Mahdi Kadhim. Isolation and Ethical Clearance: The Research Ethical Identification of The Aerobic Bacteria Causing Committee at scientific research by ethical approval of Infection in AL-Diwaniya city. Al-Qadysia Science both MOH and MOHSER in Iraq. J. (2005); 11(2):113- 125. Conflict of Interest: Non 13. Alash Sameer Abdul Ameer Abid Ali. Study the Prevalence of Bacterial Conjunctivitis in Iraq, Iraqi Funding: Self-funding Journal of Science.(2015); 56 (4): 3371-3375. Medico-legal Update, October-December 2020, Vol. 20, No. 4 743 14. Thewaini Qasim N. and Abed-Al sahib Zahraa A. of patients with Conjunctivitis In Tikrit Teaching Cryptic and Non cryptic Bacterial Ophthalmitis, Hospital,Microbiological study of patients with Journal of Babylon University/Pure and Applied Conjunctivitis In Tikrit Teaching Hospital, Tikrit Sciences. (2014); 22(6): 1848. Medical Journal. (2005); 11(2): 28-34. 15. AL-ALANI Laith M., SALMAN Samera M., 17. Abid Abdulnabi J. and Ewadh Ruqaia M.Etiology MOHAMED Marwa J., ABED SAMERA T., of Bacterial Eye Infections and Determination of ABOD Amal D., EBRAHEIM Muna A and Immune Response of Infected Patient, Medical FARHAN Anmar M. Isolation and identification Journal of Babylon. (2012); 9 (4):1021. of microbial flora in eye and study the effect of 18. Aycinena AR, Achiron A, Paul M, Burgansky- eye liner and contact lenses using on the microbial Eliash Z. Incision and Curettage Versus Steroid flora on it, AL-Anbar University Journal of Pure Injection for the Treatment of Chalazia: A Meta- Sciences.(2009); 3(2). ISSN: 1991-8941. Analysis. Ophthalmic Plast Reconstr Surg. (2016); 16. Al-Dorri Alaa Zanzal Ra’ad and Al-jebouri 32(3):220-4. [PubMed] Wa’ad Mahmood Ra’uf. Microbiological study